Posted by eHealth Source

What updates does 2018 have in store for MIPS

Updates in Merit-based Incentive Payment System (MIPS)?

MACRA, that is the Medicare Access and CHIP Reauthorization Act has finally replaced the old, and some would say, flawed SGR (Sustainable Growth Rate). Under MACRA, we get the two-track QPP (Quality Payment Program) which aims to put emphasis on payment models that are based on value.

It’s an opportunity for entities to receive funding assistance, so that can they further develop, improve, update, and expand.

Below are the entities, which help in leading or supporting the development priorities for the CMS Quality Measure Development Plan, through their perspectives on patients and speciality in medicine.

These entities, that are invited to apply, as shareholders for this opportunity, include:

  • Educational institutions
  • Clinical speciality societies
  • Independent research organizations
  • Clinical professional organizations
  • Patient advocacy organizations
  • Health systems
  • Other such entities which are engaged in the development of quality measures

Cooperative agreement priorities – What are they?

The aim of CMS Quality Measure Development Plan was to strategize the designing of QPP measure, in accordance with the section 1848(s)(1) of the Social Security Act, and as has been added by the section 102 of the MACRA. The priorities for quality measurement shared here, are on similar lines as the aims and priorities of the Measure Development Plan.

These goals have been carefully guided by the Meaningful Measurement framework, in order to find nothing short of highest priorities to measure and improve quality. This, in turn, propels the achievement of high quality results for people with Medicaid, CHIP, and Medicare. A great scope of improvement, therefore, can be seen in the areas of patient care and outcomes.

These cooperative agreements provide support to the external stakeholders, so that they can expand QPP further, and dedicate more focus to  patient perspectives, and reduce the reporting burden, as much as possible, for clinicians.

These are some of the things that cooperative agreements will look forward to developing, with highest priority:

  • Outcome measures
  • Care coordination measures
  • Patient reported outcome
  • Patient experience measures
  • Functional status
  • Measures of appropriate use of services, that would include measures of overuse

What is MIPS?

One of these two programs is MIPS (Merit-based Incentive Payment System), and the other one is Advanced Alternative Payment Model (AAPM). The former has been designed to replace three already existing programs, while adding a performance category of it own.

Here are the performance categories, based on which, MIPS makes adjustments to payments:

  • Quality, which is based upon the PQRS (Physician Quality Reporting System),
  • Cost, that is based upon the VBPM (Value-based Payment Modifier),
  • Promoting Interoperability (PI), which is based upon the Medicare EHR Incentive Program (Meaningful Use), and
  • Improvement Activities, which is the brand new category just added.

How are payments adjusted, via MIPS?

Each category has a weightage, and this quantity is used so as to get a final score that should lie between 1 to 100. In addition, there is also a performance threshold already decided, against which every group’s end score is compared to. This comparison, in turn, is what decides the final payment adjustments.

Performance Category 2018 2019 2020
Quality 50% 30% 30%
Cost 10% 30% 30%
Promoting Interoperability 25%* 25%* 25%*
Improvement Activities 15% 15% 15%

So, for example, the performance period for the year 2018 has had its performance threshold set at 15 points. Therefore,

  • If the end scores are above this threshold, they’ll get a positive payment adjustment.
  • If the end scores are below this threshold, they’ll get a negative payment adjustment.
  • ECs or eligible clinicians who fall in the last quartile, will be receiving most of the payment adjustment given for that performance period.
  • If the end scores turn to be equal to the threshold, then there will be neutral payment adjustment received by them.

Payment adjustments are made on a sliding scale, in a way that maintains the neutrality of the final budget. That is the reason, why the physicians who have higher end scores, may even get a positive payment adjustment up to 3 times the baseline positive payment adjustment set for a given year. Also, for any given year, the performance adjustments are based upon the performance from two years ago. Therefore, 2018 performance would be considered to make adjustments in the year 2020.

Here’s the sliding scale for the adjustments:

2018 2020 ±5%
2019 2021 ±7%
2020 2022 ±9%
2021 2023 ±9%

What are Exceptional performers?

If there’s been a some additional performance threshold, it could receive up to an additional 10% positive payment adjustment on the sliding scale. These are called exceptional performers, and for the year 2018, the threshold for an exceptional performance has been established as 70. What makes these performers unique, is that their adjustments are made outside of budget neutrality

How do ECs participate in this process?

Physicians have the choice to either participate individually, or in a group. For the latter, the whole group would have a single TIN, that is Tax Identification Number. It means, whatever the end score for MIPS is, every NPI (National Provider Identifier) under the TIN would have that same score applied to it. It goes without question, that no two groups can share the same TIN.

Which ECs are not included in the MIPS?

Those who administer care to 200 or less Medicare Part B patients, or who have $90,000 or less in allowed charges for Medicare Part B.

Those who are still in the very first year of participating in Medicare.

Those who have partially or fully qualified AAPM (Advanced Alternative Payment Model), and who further are qualifying for the AAPM bonus.

Those ECs who gain eligibility under MIPS will witness a 0.25% hike in their PFS (physician fee schedule), beginning from the year 2026. ECs who are in AAPM, on the other hand, will see a hike of 0.75% in their PFS, which again should get updated, starting 2026.

EHealthSource was designed MIPS to tie payments to quality and cost efficient care, increase the use of healthcare information, and reduce the cost.


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